The aim of this study was to systematically review the effectiveness of music on pediatric health-related outcomes. Five electronic databases were searched for randomized controlled/crossover trial designs published between 1984 and 2009. Eligible studies used music as a therapy or intervention, included participants 1 to 18 years, and focused on at least one health-related outcome (with the exclusion of procedural pain). Seventeen studies met the inclusion criteria. Quantitative synthesis was hampered by an inability to aggregate data arising from heterogeneity of interventions, outcomes and measurement tools. Qualitative synthesis revealed significant improvements in one or more health outcomes within four of seven trials involving children with learning and developmental disorders; two of three trials involving children experiencing stressful life events; and four of five trials involving children with acute and/or chronic physical illness. No significant effects were found for two trials involving children with mood disorders and related psychopathology. These findings offer limited qualitative evidence to support the effectiveness of music on health-related outcomes for children and adolescents with clinical diagnoses. Recommendations for establishing a consensus on research priorities and addressing methodological limitations are put forth to support the continued advancement of this popular intervention.
Formally defined, music therapy is the systematic use of music or musical elements—along with the resulting interpersonal relationship with a trained music therapist—to achieve optimal health outcomes for a client or group of clients [
Six meta-analyses examining the use of music in the context of pediatric healthcare have been published [
The three remaining meta-analyses focused on specific populations. Consistent with reviews in adult mental health [
Although these meta-analytic findings are supportive of the effectiveness of music, the reviews are narrow in focus. For example, of notable absence are children with acquired and/or congenital physical disabilities despite the use of music therapy as a habilitation tool with these populations [
A systematic review of the peer-reviewed literature was undertaken following the guidelines outlined in the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) Statement. This statement includes a 27-item checklist to improve the conduct of systematic reviews and meta-analyses of health care interventions by ensuring transparent and complete reporting [
The search strategy and database selection were developed through consultation with a research librarian. The search strategy contained a broad series of subject headings and keywords relating to music or music therapy and outcome-driven research design. Previously published meta-analyses were also reviewed to guide the development of the search strategy and identify pertinent publications [
Example of series of keywords and descriptors used to search the Ovid Medline database.
Retrieved records were imported into RefWorks and duplicates removed [
The focus of this paper was to determine the effectiveness of music as an intervention or therapy, regardless of delivery mode (i.e., by a trained music therapist, health professional, or researcher). Thus, studies examining music education, acoustic or auditory stimulation, or nonmusical sounds (e.g., white noise) were excluded. Given the recent systematic review examining RCTs for procedural pain and anxiety in children [
Data from included studies were extracted and compiled by KTN and verified by SK and AL using a standard form. Table
Characteristics of eligible studies.
Study | Participants | Intervention | Dosage | Quality | |||||||||||
First Author, Year | Country | Recruitment setting | Study design | N (n males) | Clinical population | Age range (years) | Treatment | Music delivery | Music type | Participant involvement | Delivery format | Intervention format | No. of sessions (time) | No. of weeks | PEDro score (sum/10) |
Learning and developmental disorders | |||||||||||||||
Aldridge, 1995 [ | Germany | Private practice clinic | Crossover RCT | 8 (2) | Developmental delay | 4–6.5 | Group 1 | MT | L | A | O | I | 24 (30 m) | 48 | 5 |
Claussen, 1997 [ | USA | Special education facility | Parallel RCT | 21 (12) | Learning disabilities | 9–11 | Group 1: Familiar music; Group 2: Verbal condition; both groups rehearsed multiplication problems | R | R | P | O | S | 1 ( | 3 | |
Buday, 1995 [ | USA | Public school (special education program) | Crossover RCT | 10 (8) | Autism | 4–9 | Group 1 | R | R | P | O | S | 8 (n/a) | 2 | 6 |
Kim, 2008 [ | Korea | Ambulatory care clinic | Crossover RCT | 10 (10) | Autistic disorder | 3–5 | Group 1 | MT | L | A | O | I | 12 (30 m) | 24 | 4 |
Pratt, 1995 [ | Canada | Community | Parallel RCT | 19 (17) | ADD or ADHD | 6–18 | Neurofeedback sessions with or without background classical music | R | R | P | O | S | 39 ( | 13 | 3 |
Rickson, 2003 [ | New Zealand | Special education residential facility | Parallel RCT | 15 (15) | Intellectual, social and emotional deficits including ADD/ADHD | 11–15 | Group 1 | MT | L & R | A & P | G | S & I | 16 (30–45 m) | 8 | 3 |
Rickson, 2006 [ | New Zealand | Special education residential facility | Crossover RCT | 13 (13) | ADHD and other comorbid disorders | 11–16 | Group 1 | MT | L | A | G | S & I | 16 (30–45 m) | 20 | 2 |
Stressful life events | |||||||||||||||
Baker, 2006 [ | Australia | ESL secondary school | Crossover RCT | 31 (11) | Newly arrived immigrant and refugee adolescents | 11–16 | Groups 1 | MT | L & R | A & P | G | S & I | 20 (30–40 m) | 20 | 6 |
DeLucia-Waack, 2007 [ | USA | Elementary school | Cluster parallel RCT | 134 (67) | Children from divorced and/or separated families | 5–10 | Group 1 | HP | R | A | G | S | 8 (45 m) | 8 | 3 |
Hilliard, 2007 [ | USA | Elementary schools | Cluster Parallel RCT | 26 (14) | Children experiencing bereavement | 5–11 | Group 1 (n=8): Orff-based music therapy; Group 2 ( | MT & HP | L | A | G | S | 8 (60 m) | 8 | 4 |
Mood disorders and related psychopathology | |||||||||||||||
Field, 1998 [ | USA | Ambulatory care clinic | Parallel RCT | 28 | Chronic depression | 14–19 | Group 1 | R | R | P | O | S | 1 (23 m) | 3 | |
Wooten, 1992 [ | USA | Inpatient psychiatric facility | Crossover RCT | 35 (14) | Psychopathology (affective, behavior, or substance abuse) | 12–18 | Group 1 | R | R | P | O | S | 2 (20 m) | 3 | |
Acute and/or chronic physical illness | |||||||||||||||
Colwell, 2005 [ | USA | In-patient | Parallel RCT | 24 (15) | Acute or chronic illness ( | 7–18 | Group 1 | MT | L | A | O | I | 1 (45–60 m) | 3 | |
Robb, 2008 [ | USA | In-patient | Parallel RCT | 83 (n/a) | Chronic illness (100% oncology) | 4–7 | Group 1 | MT & HP | L & R | A & P | O | S | 1 (15–20 m) | 3 | |
Froehlich, 1984 [ | USA | In-patient | Parallel RCT | 39 (22) | Acute or chronic illness | 5–12 | Group 1 | HP | L | A | O | S | 1 (30 m) | <1 | 4 |
Grasso, 2000 [ | Australia | Ambulatory care clinic | Parallel RCT | 21 (10) | Cystic fibrosis | 0.38–2 | Group 1 | MT | R | P | O | S | 42–168 (30 m) | 12 | 5 |
Oelkers-Ax, 2008 [ | Germany | Community | Parallel RCT | 58 (40) | Migraine | Mean = 10 | 8-week baseline condition; Group 1 | MT | L | A | O | S | 12 (n/a) | 28 | 6 |
RCT: Randomized controlled trial.
Outcome measures and results of eligible studies.
Study | Outcome | Findings | |||||
Trial | Measure | Scale | Analysis | Result | |||
Learning and developmental disorders | |||||||
Change from baseline: | Group A (MT) = 7.96 | Group B (no MT) = 4.60 | .045 | ||||
Aldridge et al., 1995 [ | Developmental milestones (locomotor development; personal-social; hearing and speech; hand-eye coordination; performance tests; practical reasoning) | Griffiths Scale | Repeated measures ANOVA | ||||
Change after crossover: | Group A (no MT) = 3.92 | Group B (MT) = 5.83 | NS | ||||
Claussen and Thaut, 1997 [ | Recall accuracy of multiplication tables | Test of multiplication problems | ANCOVA | Mean accurate responses (SE): | Pre | Post | |
Music | 0.9 (.46) | 3.5 (.59) | .0001 | ||||
Verbal | 1.6 (.48) | 2.1 (.62) | |||||
Buday, 1995 [ | Number of correctly imitated signed and spoken words | Scored by independent observer | ANOVA | Group means (SD) for correctly imitated words: | Music | Rhythm | |
Sign | 5.10 (2.89) | 4.00 (2.83) | |||||
Speech | 4.20 (3.36) | 3.20 (2.94) | |||||
Kim et al., 2008 [ | Joint attention skills and pro-social behaviors; nonverbal social communication skills | Pervasive Developmental Disorder Behaviour Inventory-C (PDDBI); Early Social Communication Scales (ESCS); Video analysis | Repeated measures ANOVA | Effect size (95% CI) for music therapy vs. play session: | |||
PDDBI: 0.79 ( | NS | ||||||
ESCS: 0.97 (+0.20 to +1.74) | |||||||
Duration of behaviors: | |||||||
Eye contact: MT > Play | |||||||
Turn taking: MT > Play | |||||||
Pratt et al., 1995 [ | EEG frequency band activity; severity of ADD/ADHD; adaptive and maladaptive behaviours | EEG signal (A620 Assessment Software); McCarney Test (parents); Likert scale (parents) | Wilcoxon signed-rank test |
Pre-post change in EEG power for ADD children | |||
Band Activity | Music | No music | |||||
Beta band | NS | ||||||
Alpha band | NS | ||||||
Theta band | NS | ||||||
McCarney Test | NS | ||||||
Likert Ratings | NS | ||||||
Rickson and Watkins, 2003 [ | Aggressive behaviours: disruptive and antisocial | Developmental Behaviour Checklist (DBC); Video analysis | Repeated measures ANOVA |
Mean change for DBC Subscale | |||
Teacher | Parent | ||||||
Group 1 (Control) | |||||||
Group 2 (MT) | NS | ||||||
Group 3 (MTl) | +2.83 | +1.00 | NS | ||||
Positive & negative events: | |||||||
Group 1 vs Group 2 vs Group 3 | NS | ||||||
Rickson, 2006 [ | Motor impulsivity | Synchronised tapping task (STT); Conners' Rating Scales (teacher rated) | Unpaired | Group (Mean # of errors): | Pre | Post | |
(1) NO music | 20.13 | 22.43 | |||||
(2) AB (Improv/Instruct) | 20.91 | 11.56 | .02 | ||||
(3) BA (Instruct/Improv) | 20.89 | 12.18 | .02 | ||||
Conner's DSM IV Total: | |||||||
Group 1 > (Group 2 + Group 3) | .02 | ||||||
Conner’s Global Index Scale: | |||||||
Group 1 > (Group 2 + Group 3) | .03 | ||||||
Stressful life events | |||||||
Baker and Jones, 2006 [ | Classroom behaviours: externalising, internalising, school, Behavioral Symptom Index (BSI), adaptive skills | Teachers completed Behaviour Assessment System for Children (BASC) | MANCOVA | F-statistic (df = 21) for Treatment (music/no music) × time: | Externalising: 2.21 | .01 | |
Internalising: 0.32 | NS | ||||||
Behavior Symptom Index: 2.57 | .07 | ||||||
School problems: 0.89 | NS | ||||||
Adaptive skills: 0.53 | NS | ||||||
DeLucia-Waack and Gellman, 2007 [ | Beliefs about divorce and affective measures | Revised Children's Manifest Anxiety Scale (RCMAS); Children's Depression Inventory (CDI); Children's Beliefs about Parental Divorce Scale (CBPDS) | MANOVA | Treatment (music therapy/ | Anxiety Depression Irrational Beliefs | F (6,127) = 0.487 | NS |
F (10,123) = 1.416 | NS | ||||||
F (12,111) = 0.988 | NS | ||||||
Hilliard, 2007 [ | Grief symptoms and behavioural distress | Behaviour Rating Index for Children (BRIC); Bereavement Group Questionnaire for Parents (BP) | Within-group Wilcoxon signed-ranks tests | Change in BRIC: | Control | NS | |
Music therapy | .01 | ||||||
Social work | .04 | ||||||
Change in BP: | Control | NS | |||||
Music therapy | .01 | ||||||
Social work | NS | ||||||
Mood disorders and related psychopathology | |||||||
Field et al., 1998 [ | Behaviour; mood; stress; left frontal activation | 1) Behaviour Observation Scale (BOS); | Repeated measures MANOVA and post hoc tests | Mean scores for music group (control group): | |||
Before | During | After | |||||
(1) 14.0 (15.1) | 14.2 (14.9) | 14.7 (14.8) | NS | ||||
(2) 9.5 (8.9) | –- (–) | 9.7 (9.1) | NS | ||||
(3) 1.3 (1.5) | –- (–) | 0.5 (1.3) | .02 | ||||
.05 | |||||||
Wooten, 1992 [ | Fluctuations in mood | Positive and Negative Affect Scales (PANAS) | Repeated measures ANOVA | Negative affect |
Treatment (none, rock or heavy metal) × time: | NS | |
Positive affect |
Treatment (none, rock or heavy metal) × time: | NS | |||||
Acute and/or chronic physical illness | |||||||
Colwell et al., 2005 [ | Self-concept | Piers-Harris Children's Self Concept Scale (PHCSS)* | MANCOVA | Pre- to post-test mean differences: | Music composition 2.08 | Art composition 2.00 | NS |
Robb et al., 2008 [ | Frequency of coping related behaviors | Time sampling of observed behaviours: | Repeated measures ANOVA and post hoc tests | AME | ML | ASB | |
Positive facial affect | 18.63 (13.0) | 7.7 (7.5) | 2.0 (2.3) | AME>ML, ASB; <.0001 | |||
Active engagement | 26.03 (4.1) | 15.65 (6.2) | 15.17 (4.9) | AME>ML, ASB; <.0001 | |||
Active initiation | 14.19 (8.3) | 15.89 (11.2) | 7.43 (6.6) | AME, ML>ASB; <.05 | |||
Froehlich, 1984 [ | Verbalization of hospital experiences | Standardized questionnaires and coding system to rate quality of responses | Chi-Square | % of responses coded: | Music therapy | Play therapy | |
Answer | 90% | 62% | <.10 | ||||
No answer | 10% | 38% | |||||
Grasso et al., 2000 [ | Enjoyment and perception of time | 7-point bipolar Likert-type Child* & Parent Enjoyment scale (proxy) and Caregiver Perception of Time survey | Kruskal-Wallis | Median (range) group change for Child enjoyment: | |||
Treatment music (TM) | Familiar music (FM) | No music (NM) | |||||
+1.25 ( | +0.75 ( | TM vs NM;.03 | |||||
FM vs NM; NS | |||||||
Oelkers-Ax et al., 2008 [ | Relative reduction in headache frequency | Child-adapted daily headache diary | % reduction from baseline°: | Butterbur, Placebo, Music | |||
Repeated measures | Post-test | M>P;.005 (at T1) and .018 (at T2) | |||||
ANOVA | Follow-up | B>P; NS (at T1) and .044 (at T2) |
Data quality was assessed (SK and AL) using the PEDro Scale [
Because of heterogeneity in the study populations, interventions used, and outcome measures applied, it was neither feasible nor appropriate to conduct a meta-analysis. Therefore, the findings were synthesized in a qualitative manner. To facilitate this synthesis, the final studies were grouped into four broad categories based on the primary diagnoses or conditions of the study participants. “Learning and developmental disorders” includes children with autistic spectrum disorders, attention deficit-hyperactivity disorder, learning disabilities, and developmental delay. The category “stressful life events” includes children experiencing losses or trauma such as bereavement, divorce, or refugee status. A third category—“mood disorders and related psychopathology”—includes children diagnosed with depression or other psychiatric conditions. The final category “acute and/or chronic physical illness” was reserved for children with physical illnesses or conditions.
Of the 2411 titles identified, 17 studies met the inclusion criteria [
Flow of studies through the systematic review process.
Selected trials included a total of 575 participants; approximately 50% were male (1 study did not provide data by gender). Sample sizes ranged from 8 to 134 participants with a median trial sample size of 22. With the one exception of a trial involving participants less than 2 years of age [
Outcomes included observed behavior and performance [
Methodological quality was poor with an overall median PEDro score of 3 (min = 2, max = 6); classifying the studies, 9 were of low quality (score
Study objectives varied greatly; music was used to influence cognitive functioning [
Seven trials exclusively employed prerecorded music [
Sessions were offered one-to-one with individual participants [
Two trials investigated the influence of music therapy on normative development and cognitive functioning in children with developmental delay [
Two small trials
Impulsivity and related behavioral outcomes were the focus of three low quality trials involving youth with attention deficit disorders [
Coping was the focus of three trials of low to moderate quality involving children who had experienced a major upheaval in their lives [
Two low quality trials involving adolescents with mood and related affective disorders produced unclear findings [
Three low to moderate quality trials examined the effects of music therapy on coping among hospitalized children [
Grasso et al. examined the effects of “treatment” music (specially composed by a music therapist) or familiar children’s music compared with no music on child and parent experiences of chest physiotherapy in infants and toddlers with cystic fibrosis. This moderate quality trial found treatment music resulted in a significantly more positive experience for parents and children as compared to familiar music or no music. Neither type of music changed parents’ perceptions of time taken to complete therapy [
Last, symptomatology was the focus of a trial of moderate quality by Oelkers-Ax et al. comparing the effect of individualized music therapy emphasizing relaxation and techniques for coping with pain, butterbur root extract, or a placebo in combination with education and symptomatic pain treatment on the frequency and severity of migraine headaches. Relative to the placebo, both interventions reduced migraine frequency over an extended period. Music therapy, however, had a more immediate and lasting impact compared to the pharmacological approach, with significant reductions in migraine frequency posttreatment and on follow-up [
Two trials with low to moderate quality PEDro scores targeted cognitive functioning and reported improvements in recall accuracy of multiplication tables [
Two trials with similar moderate PEDro scores examined the acquisition of social skills and achievement of developmental milestones using standardized assessments of observed behavior following music therapy [
Coping and affect were the focus of nine trials [
Differential findings were evident for three low to moderate quality trials assessing internalizing and externalizing behaviors using standardized measures [
Five trials targeted frequency of symptoms related to clinical diagnoses with varied success [
Two trials with similar low PEDro scores examined change in affective patterns of EEG responding following passive listening to recorded music [
No clear influence of participant involvement (active versus passive) or dosage (length of exposure in minutes) was identified among the treatment effects. Interventions led by a music therapist were more likely to yield significant effects than interventions led by a health professional or researcher.
Over a 25-year period, 17 RCTs examining the effectiveness of music on health-related outcomes in children were identified. While methodological limitations and clinical heterogeneity preclude drawing firm conclusions, a qualitative synthesis of findings suggest some effectiveness of music as an intervention in pediatric healthcare. Reviewing findings as a function of diagnostic category, treatment effects were mixed for children with learning and developmental disorders [
Turning to clinical outcomes, exposure to music positively affected cognitive functioning and was associated with higher recall accuracy [
Although previous papers have explored the influence of intervention characteristics [
To address the limitations of previous systematic papers [
Within this sample, variation in outcomes and/or outcome measures precluded formal aggregation of the results and completion of a meta-analysis—thereby limiting definitive conclusions of the effectiveness of musical interventions. Despite the systematic design of this paper, the exclusive focus on published trials does raise the risk of a publication bias and overestimation of treatment effects [
The issue of methodological quality has been raised repeatedly in both the pediatric and adult literature around music therapy. It is, however, but one of the issues impeding meta-analytic synthesis of the music literature. Of perhaps equal concern is the lack of standardization of interventions, including both music therapy and musical interventions, and appropriate controls. Further limiting the task is the extensive outcome and measurement heterogeneity within and across diagnostic groups [
Collectively, these factors restrict the collection of definitive data on the effectiveness of music in pediatric healthcare. The issue is not simply a lack of research but rather a lack of high quality research. As other authors have noted, the field would benefit from a strict adherence to methodological quality [
This paper is the first systematic review to examine the effectiveness of music among varied pediatric conditions and settings. The findings offer limited qualitative evidence to support the effectiveness of music for children with learning and development disorders and acute and/or chronic physical illness, and children experiencing stressful life events. No evidence to support the effectiveness of music for children with mood disorders and related psychopathology was found. From a health outcomes perspective, music may be used to enhance cognitive abilities [
No funding was received for this project.
The authors would like to thank Pui Ying Wong for her assistance with the literature search. K. Treurnicht Naylor and S. Kingsnorth have contributed equally to this work.